1.1 History Taking: Common Surgical Symptoms

1.2 Upper GI Symptoms

1.3 Lower Gi Symptoms

1.4 Hepatobiliary Symptoms

1.5 Peripheral Arterial Disease Symptoms

1.6 Urology Symptoms

1.7 Differential Diagnosis of the Acute Abdomen

1.8 Differential Diagnosis of Right Upper Quadrant (RUQ) Pain

1.9 Differential Diagnosis of LOQ Pain

1.10 Differential Diagnosis of Umbilical Pain

1.11 Differential Diagnosis of Right/Left Flank Pain

1.12 Differential Diagnosis of Diffuse Abdominal Pain

1.13 Differential Diagnosis of Right Iliac Fossa (Rif) Pain

1.14 Differential Diagnosis of Left Iliac Fossa (LIF) Pain

1.15 Differential Diagnosis of Suprapubic Pain

1.16 Surgical Incisions/Scars

1.17 Drains

1.18 Nutrition In Surgical Patients

1.19 Medications In Surgery

1.20 Fluids In Surgical Patients

1.21 Sepsis

Principles of Surgery

History Taking: Common Surgical Symptoms

Introduction

• Introduce yourself: State your name and your job title.
• Identity: Make sure you are speaking to the correct patient (name and date of birth), ask the patient where they are from, and their job occupation/retired.
• Consent: Explain the reason for seeing the patient (“I would like to ask you some questions about your symptoms/what brought you to the emergency department today, would that be OK?”).
• Positioning: Make sure the patient is comfortable. Try to sit at the same level as them.

Presenting Complaint

• Ask the patient to describe their problem using open questions (e.g., “What’s brought you into hospital today? What was the reason you came to the emergency department/clinic today?”).
• The presenting complaint should be expressed in the patient’s own words (e.g., “I have pain in my tummy/around my belly button”).
• Use ICE to explore the patient’s ideas, concerns and expectations (ICE).

History of Presenting Complaint–Pain

• Encourage patients to tell you their story through active listening. Start with open questions and continue with more focused questions to rule out differential diagnoses. Questions with options might be necessary in some instances if the patient is not able to provide an answer for your open question (what kind of pain are you experiencing? I don’t know. Dull, sharp, crampy etc?), however leading questions must be avoided if possible.

Mnemonics to Help Remember Important Questions

• SR.COPD.SARAH mnemonic described below works for all causes of pain and can also be used for other symptoms –Use it while you work out your differential diagnoses.
• Alternatively, you can use the mnemonic SOCRATES (Site, Onset (When/How), Character, Radiation, Associated symptoms, Time (What were you doing when you experienced the pain?/Has the pain changed since you first experienced it? How has the pain changed over time?), Exacerbating/relieving factors, Severity (1-10))

Site

• “Where is the pain?” “Can you point to where the pain is?” ‘Can you point with one finger where it is or is it more generalized?’ ‘Was the pain always in this position or has it changed?’

Radiation

• “Does the pain move or spread out anywhere?”
• Gallbladder disease: Radiates to the mid back (right scapular tip) and/or right shoulder.
• Pancreatic disease: Spreads through to the back.
• Ureteric disease: Loin to the groin pain.

Character: If necessary, give examples but avoid leading questions.

• ‘What kind of pain is it?’ “How would you best describe this pain?”
• Sharp like a needle/burning or stinging, dull or throbbing.
• Restless/prefer to lie still (colicky pain).
• ‘Does the pain come and go or is it always there?’ (constant versus intermittent). If intermittent, ask how long it lasts for and how often it comes.

Onset

• ‘When did it start?’
• ‘How did it start?’ Suddenly/gradually?
• What were you doing when the pain started?
• Did the pain wake you up during the night or did you wake up and then noticed the pain?

Periodicity

• Time of day: Night (PUD vs gallstone)
• Worse after eating fatty foods
• “Has the pain changed since it started? How has the pain changed over time? Does the pain build up and get worse over minutes/hours?” (crescendo pain) – Always the same? Improving/getting worse?

Duration

• “How long have you experienced the pain?”

Severity (Out of 10)

• Maximum pain and baseline pain

Associated symptoms

• Vomiting: Content (Quantity/quality), frequency, exacerbating and relieving factors. If presence of blood, you must ask the colour (dark brown, bright red), the amount, how often and for how long.
• PR bleed/melaena: Quantity/quality (bright red/dark brown)/duration/how often. Black, tarry and sticky stool with strong smell is suggestive of melaena.
• Hematemesis: ‘Any blood in your vomit? What colour is it? Is it bright red? Were there small black bits like tea leaves or coffee grounds in your vomit? Also ask about duration, frequency and quantity.
• Dysuria: Stinging when you urinate.
• Tenesmus: Feeling of incomplete defecation after a bowel motion.
• Weight loss
• Any lumps or bumps? (lymphadenopathy, hernias)

Relieving factors

• ‘Is there anything that make your pain better?’
• Example - Pancreatitis: pain might be relieved when leaning forward or curling into a ball; pain can get worse when lying in a flat position. Eating and drinking might make symptoms worse. Relief with simple analgesia?

Aggravating factors

• Is there anything that make your pain worse?’ (Deep breath/walking or moving/ coughing/ position)

History of this symptom

• “Have you ever experienced this type of pain before?”

Risk Factors

• If not previously asked, you must explore risk factors by asking specific questions to emphasize your primary differentials and/or to rule out other differentials before proceeding with the patient’s past medical/surgical history.
• Example – RUQ pain (?cholecystitis ?cholangitis): history of gallstones? Previous similar episodes of pain? Fatty meal prior to onset of symptoms? Jaundice? Pale stools? Dark urine? Fever? Weight loss?

Past Medical/Surgical History

• Explore previous conditions/previous admissions (childhood, medical, surgery, obstetrics/gynaecological, psychiatric conditions/diagnosis). ‘Any medical conditions in your past?’, ‘Any surgeries/operations in the past?’, ‘ Any previous admissions to a hospital?’, ‘Any blood transfusions in the past?’, Any recent scans/investigations?’
• Always explore positive findings (e.g., diabetes – which type? When was it diagnosed? How is it controlled?; surgery – when? Reason? Post-operative course and complications)
• If relevant, ask about additional specific risk factors that were not previously asked.

Medication History

• Medication, dose, frequency, route
• Over-the-counter (OTC) medications

Allergies

• Specify what type of reaction the patient had to the drug: Rash/nausea/anaphylaxis.

Family History

• Ask the patient about any family diagnosis or conditions relevant to the presenting complaint including the age of onset of the disease (e.g., malignancies – ask how old the relative was when he/she was diagnosed with it).

Social History

• Alcohol intake (units/week).
• Smoking history: What do they smoke? Current or ex-smoker? (establish the pack-year). Remember to ask about vaping history.
• Recreational drugs/intravenous drugs
• Home environment: How is the patient managing at home? Independent? Presence of carers (if so, how often?) Walking aids?
• Work environment: explore occupational risk factors (current and previous jobs) for medical/surgical conditions relevant to the case.
• Recent travel history: explore travel history when relevant to the case (any recent trip abroad, long haul flights, infectious disease risk)

Systems Review

• Run through a full list of symptoms from major systems: Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Neurological, Psychiatric, General Review (if not already explored earlier in the history, ask, for example, about weight loss, rashes, joint pain, lumps, appetite changes etc).

Summary

• Name and age of the patient, presenting complaint, relevant medical history (relevant positives and relevant negatives). Present it in a concise and structured fashion.
• Point out the primary diagnosis you are concerned about and potential differential diagnosis.
• Explain a brief investigation and management plan.
• “I would like to introduce/present Mr Joe Bloggs, a 73-year-old retired accountant from Clontarf, who presented with a 1-day history of intermittent right upper quadrant pain ….”

Upper GI Symptoms

Dyspepsia

• Indigestion. Symptoms include persistent or recurrent abdominal pain or abdominal discomfort centred in the upper abdomen, bloating during or after eating, acid reflux, heartburn and/or eructation (burping).
• “Discomfort” refers to a subjective, negative feeling that does not reach the level of pain according to the patient.

Dysphagia

• Sensation of difficulty or abnormality of swallowing.
• How did it start?
• Worsening or staying the same?
• Able to swallow solids or fluids only?
• Able to swallow saliva?
• How has it progressed over time?
• Constant or intermittent?
• Associated symptoms (e.g., weight loss, chest pain)?
• Previous similar episodes?

Gastro-Oesophageal Reflux Disease (GORD)/Heartburn

• Stomach content flows back into the oesophagus. Can cause a burning sensation in the epigastrium and/or chest (heartburn), bitter-tasting/sour backwash of food/liquid into throat or mouth.
• Ask how frequently it occurs.
• Precipitating factors (lying flat, large meals, any food avoidance?).

Haematemesis

• Vomiting fresh blood as a result from bleeding from the upper gastrointestinal tract.
• Coffee ground vomitus represent old or low-volume gastric bleeding. Causes include, for example, peptic ulcers, oesophageal varices and gastritis. Red blood is usually either variceal or arterial (e.g., bleeding duodenal ulcer).
• Blood appearing only after repeated vomiting (“blood-streaked vomitus”) may represent traumatic laceration and bleeding of the gastro-oesophageal mucosa (Mallory Weiss tears) or other causes such as gastritis.

Lower Gi Symptoms

Altered Bowel Habit

• Important to explore the symptom’s duration (acute or chronic) and associated factors (presence of blood or mucus, weight loss, rash etc).
• May indicate underlying bowel cancer or inflammatory bowel disease.
• May be change in frequency, diarrhoea/constipation, or change in stool consistency.
• Presents with haematochezia (bright red blood, clots or burgundy stools) or melena.
• Bright red blood is more often seen in anorectal and distal colonic sources but remember that it can also be caused by vigorous upper gastrointestinal bleeding.
• Haemorrhoids or anal bleeding: Bright red in colour and generally only on wiping.
• Haemorrhoids often cause painless rectal bleeding, stain the toilet paper, drip into the toilet bowl and/or coat the stool after a bowel movement. Haemorrhoids are not typically painful unless thrombosed.
• Anal fissures can cause a small amount of bright red bleeding on wiping and painful bowel movements (sensation of anal tearing or burning). Dyschezia refers to severe pain on defecation despite having a normal defecation reflex

Rectal bleeding: Usually on the surface of the stool.

• Left colon bleeding: usually bright red (e.g., diverticular haemorrhage: usually painless severe bleeding with clots).
• Proximal colonic bleeding: maroon in colour, mixed up with the stool
• and might be accompanied with clots (maroon red in colour and loose?). Keep in mind that brisk and massive right sided colonic bleeding can also cause bright red blood per rectum.
• Other causes of rectal bleeding: bowel/rectal cancer, colonic polyps, diverticular disease, radiation proctitis, angiodysplasia, colitis/proctitis, inflammatory bowel disease, among others.

Tenesmus

• Sensation of not fully emptying bowels after a bowel motion. Causes include low colorectal tumour (cancer/polyp), inflammatory bowel disease, anorectal abscess, among others).

Hepatobiliary Symptoms

Jaundice

• Yellow discolouration of the sclera and skin due to hyperbilirubinaemia.
• Ask for skin itch, dark urine and pale stool in every case.
• Acute onset (e.g., choledocholithiasis, cholangitis)?
• Sudden (e.g. choledocholithiasis) or gradual onset (e.g., pancreatic/biliary malignancy)?
• Constant and worsening over time (e.g., choledocholithiasis, pancreatic/biliary malignancy)?
• Intermittent/recurrent (e.g., Gilbert’s syndrome)?
• Painful (e.g., choledocholithiasis) or painless (e.g., pancreatic or biliary malignancy, hepatocellular disease)?
• Fever (e.g., cholangitis)?
• Painless and palpable gallbladder (Courvoisier sign – e.g., periampullary malignancy)?
• Associated weight loss? (pancreatic/biliary tract malignancy)
• Pruritus/itch (suggests post-hepatic obstruction cholestasis)?
• Ask when the patient last felt well.

Peripheral Arterial Disease Symptoms

Claudication

• Pain in calf, thigh or buttock precipitated by exercise and relieved by rest due to inadequate blood flow. Lower extremity peripheral artery disease is one of its main causes.
• Claudication distance: “How far can you walk before needing a rest?”
• “How long do you typically rest for before recommencing walking?”
• “When did the pain on walking first begin?”
• “Did your leg suddenly go cold with the onset of calf pain on walking and then recover?”

Rest Pain

• Severe, burning pain in limb affected by inadequate arterial flow, present at rest. Pain is neuropathic in nature due to neuronal ischaemia.
• “What makes it worse? Worse at night-time?
• “What makes it better? Do you have to hang your leg over the side of the bed?”
• “Do you have to walk around your room at night to relieve the pain?”

Urology Symptoms

Dysuria

• Pain on micturition. Urinary tract infection is one of the main differentials.
• Burning/stinging when you pass water/urine?
• Nocturia? Frequency? Hesitancy?
• Pain in lower abdomen?

Haematuria

• Presence of blood in the urine.
• Acute? Chronic? Previous similar episodes? Associated symptoms?
• “Does the blood occur at the start of urination?” (suggests bladder origin)
• “Does the blood appear at the end of urination, or during urination?” (suggests prostatic or penile origin)
• Painful (e.g., urinary tract infection, urinary stones) or painless (e.g., bladder malignancy)?

Differential Diagnosis of the Acute Abdomen

Key Points

• Formulate differential diagnoses as the history progresses. Figure 1.1
• Ask targeted questions which help to rule in or rule out your differential diagnoses as you proceed through your history.
• You should ask around 2–3 questions about each possible differential diagnosis (risk factors) to show the examiner that you are considering the likely causes for the patient’s presentation. If not elicited during the History of Presenting Complaint (HPC), these questions should be asked at the end of the HPC prior to proceeding with the Past Medical/Surgical History section. These are all “focused questions” for typical symptoms of each disease. With practice you will be able to frame them with “open questions” and use your own style of history taking. Examples: Any fever? Weight loss? Lumps or bumps? Trauma? Exposure to asbestos? Any recent long-haul flights? Anyone with similar symptoms at home? Any recent trip?

Differential Diagnosis of Epigastric PainPeptic Ulcer Disease/Gastritis

• Pain in the upper abdomen (epigastrium) caused by inflammation of the lining of the stomach/duodenum and/or peptic ulcers.
• Heartburn, indigestion, bloating.

Sensation of fullness after eating or nausea.

• Ask about risk factors including recent or long-term use of non-steroidal inflammatory drugs (NSAIDs) and alcohol misuse.
• Duodenal ulcer: Symptoms worse when the stomach is empty (e.g., nighttime, between meals, woken up with pain). Eating/Milk might relieve
• the pain.
• Upper gastrointestinal bleeding: haematemesis/coffee-ground vomit/anaemia/melaena.
• Perforated ulcer: sudden and severe upper abdominal pain that can become generalised with peritonitis (life-threatening condition).

Pancreatitis

• Severe epigastric pain with vomiting. Can be focused on the left upper quadrant and radiate through to the back.
• Constant pain, aggravated by eating and drinking, lying flat or movement (inflammation). Might be relieved by sitting upright, leaning forward or curling into a ball.
• History of similar pain before/ similar episodes/admissions? History of alcohol use? History of gallstones (recurrent right upper quadrant pain/biliary colic)?

Figure 1.1 General Guidance With Regional Differential Diagnosis of An Acute Abdomen. Locations Can Vary And Patients Might Have Different Presentations of Each Condition.

GORD

• Unpleasant taste at the back of the mouth due to acid reflux from the stomach to the oesophagus.
• Epigastric pain radiating to the chest (atypical symptom).
• Relieved by antiacids (e.g., Gaviscon) or cool drinks.

Cardiac (Myocardial Infarction (Mi)/Pericarditis)

• Chest pain, tightness or discomfort.
• Radiation to left arm, shoulder or jaw.
• Patient is short of breath/Sweaty (diaphoretic)/anxious.
• Any history of heart conditions? (e.g., heart attack or angina?)
• Pericarditis: usually acute onset of pleuritic sharp chest pain that might be alleviated when sitting up. Presentation can also be similar to a myocardial infarction (dull crushing chest pain).

Table 1.1 Acute Abdomen Investigations

Table 1.1 Acute Abdomen Investigations (continued)

Ruptured AAA

• Sudden, severe onset of abdominal pain radiating to the back.
• Dizzy, light-headed, clammy or sweaty.
• Collapse/loss of consciousness.
• Any history of poor circulation to your legs or heart disease?
• Ever diagnosed with an aneurysm?
• Explore risk factors e.g., smoking, older age, male gender, hypertension, first-degree relatives with history of AAA, hyperlipidaemia.

Differential Diagnosis of Right Upper Quadrant (RUQ) Pain

Biliary Colic

• Ingestion of a fatty meal prior to onset of pain.
• History of previous similar episodes
• Crescendo-decrescendo: Increases and decreases in intensity with time.
• Colicky: Restless with rapid escalation pain, bending over or moving to find a position of comfort.
• Pain usually lasts less than 6 hours.

Cholecystitis/Cholangitis

• Ingestion of a fatty meal prior to onset of pain.
• Radiation around the right side to the back/right shoulder/shoulder-tip.
• Constant pain, aggravated by movement (inflammation) and deep breaths.
• Cholestasis: jaundice, dark urine, pale stools, pruritus.

Hepatitis

• Constant pain, aggravated by movement (inflammation).
• Medication history, travel history and social history (alcohol and recreational drug use).

Pneumonia

• Diaphragmatic irritation from lower lobe pneumonia may cause RUQ or LUQ pain.
• Shortness of breath, productive cough.
• Chest/RUQ/LUQ pain; pleuritic and sharp/knife-like.

Differential Diagnosis of LOQ Pain

• Left lower lobe pneumonia
• Splenic abscess/infarction
• Gastric ulcer
• Herpes zoster

Differential Diagnosis of Umbilical Pain

• Appendicitis (refer to right iliac fossa [RIF] pain).
• Small bowel obstruction (SBO)–Diffuse abdominal pain
• UTI – cystitis
• Lower abdominal/pelvic pain/discomfort/pressure
• Dysuria, pyuria, haematuria, frequency, hesitancy

Differential Diagnosis of Right/Left Flank Pain

• Renal colic (as per ureteric colic–refer to RIF pain)
• Pyelonephritis
• UTI and systemic features: Fever, rigors, nausea, vomiting.
• Constant dull pain (inflammatory)
• Musculoskeletal
• Sciatica
• Lumbar disc herniation
• Bone metastases

Differential Diagnosis of Diffuse Abdominal Pain

Gastroenteritis

• Acute onset of diarrhoea +/− blood/mucus + nausea/vomiting.
• Anyone in the house with similar symptoms?

Acute Mesenteric Ischaemia

• Risks: elderly, atrial fibrillation, cardiovascular disease, history of chronic mesenteric ischemia.
• Ask for associated symptoms, e.g., vomiting, diarrhoea, ileus.
• Typically very severe pain unrelieved by analgesia.

Chronic Mesenteric Ischaemia

• Post-prandial pain
• Weight loss
• Change in bowel habit

Bowel Obstruction

• Colicky abdominal pain
• Vomiting–Green in colour (bilious) or brown (faeculent). Constipation/obstipation (no flatus in complete obstruction).
• Distension
• On examination: abdominal distention, tympanic on percussion, with high-pitched bowel sounds on early obstruction and absent sound in advanced obstruction (hypotonic bowel)
• SBO (high): First, bilious vomit; later, constipation.
• LBO (low): First, constipation; later, faeculent vomit. On exam: distension, tympanic abdomen, high-pitched bowel sounds.

Differential Diagnosis of Right Iliac Fossa (Rif) Pain

Appendicitis

• Migratory umbilical pain to RIF pain, worsening over time.
• Worse on movement or coughing (inflammation).
• Fever, chills, rigors.
• Nausea/vomiting
• Anorexia i.e., lack of appetite.
• Might be accompanied by loose bowel motions/diarrhoea
• Deep tenderness at McBurney’s point: 1/3 distance from ASIS to the umbilicus. Also rebound tenderness (peritonitis).
• Rovsing’s sign: LIF palpation increases RIF pain.
• Obturator sign: Lie supine, flex hip and knee 90 degrees. Examiner passively internally rotates the hip, causing pain. Retrocaecal appendicitis can inflame the obturator internus, which stretches with this manoeuvre.
• Psoas sign: Lie on side with knees extended. Examiner passively extends thigh, causing abdominal pain. Retrocaecal appendicitis can inflame ileo-psoas. Differential diagnosis: psoas abscess.

Ectopic pregnancy

• Full menstrual history
• LMP (first day of last menstrual period).
• Illicit normal cycle for the patient.
• Menorrhagia?
• Period late/irregular bleeding?
• Pregnant?
• PV bleeding between periods?
• Dizzy/faint/hypotensive
• Dyschezia: Painful bowel motion due to blood collecting and irritating the Pouch of Douglas.

Ruptured Ovarian Cyst

• Full menstrual history
• LMP (first day of last menstrual period).
• Period late/irregular bleeding?
• Pregnant?
• PV bleeding between periods?
• Sudden onset (unlike appendicitis).
• Vomit–vomiting with severe pain suggests ovarian torsion.

Mittelschmerz (Ovulation Pain)

• Benign pre-ovulatory lower abdominal pain
• Midcycle pain

Pelvic Inflammatory Disease (Pid)

• Ask for symptoms associated with ruptured ovarian cyst.
• Fever
• Vaginal discharge.
• Full sexual history necessary.

Inguinal hernia

• “Lump in the area before this pain began?”
• “Is the lump there all the time or does it come and go?” (incarcerated or not).
• “Lump swollen and tender now?”
• “Lump gone in the morning and reappears during the day?”
• Dragging sensation
• Strangulation: Constant pain. On exam: Fever, tachycardia, localized tenderness, irreducible hernia, skin changes

Ureteric Stone

• Severe pain
• Sudden onset
• Radiates from “loin to groin.” Restless with the pain.
• Dysuria, urgency. Vomiting.

Inflammatory Bowel Disease

• Change in bowel motion. What is normal for you?
• Haematochezia/Bloody diarrhoea.
• Systemic symptoms
• Weight loss.
• Joint pain.
• Eye trouble.
• Skin rash.
• Family history of Crohn’s disease/ulcerative colitis

Differential Diagnosis of Left Iliac Fossa (LIF) Pain

• Diverticulitis
• Change in bowel motion. What is normal for you?
• Haematochezia/Bloody diarrhoea.
• Fever, chills, rigors. Anorexia.
• Prior colonoscopy? Any abnormalities found?
• Ectopic Pregnancy (As above)
• Ruptured Ovarian Cyst (As above)
• Pelvic Inflammatory Disease (As above)
• Inflammatory Bowel Disease (As above)
• Ureteric Stone (As Above)

Differential Diagnosis of Suprapubic Pain

• Urine Retention
• UTI
• Prostatitis
• Pelvic Inflammatory Disease (As Above)
• Inflammatory Bowel Disease (As Above)
• Osteitis pubis

Table 1.2 Evaluation and Management of Acute Abdomen

Surgical Incisions/Scars

Figure 1.2 Essential components of the regional differential diagnosis of an acute abdomen.

Figure 1.3 Common open and laparoscopic scars.

Figure 1.4 Laparoscopic port sites and scar locations.

Drains

Key Points

• Drains remove collections of blood (drainage of haemothorax), fluid (ascitic drain/bile), pus (drainage of empyema or subphrenic abscess) or air (pneumothorax).
• Drains prevent accumulation of fluid around the operative site (e.g., bile after biliary surgery).
• Generally, drains are removed when its content gradually reduces in quantity and minimal amount (30-50ml/24 hours depending on the site) is draining.
• Beware of the possibility of a blocked drain if sudden stop of drainage.

Complications

• Damage to underlying structures by migration or misplacement. A route for infection.
• Blockage

Types of Drains

• Open passive drains: Provide a conduit for drainage of secretions, relies on gravity to draw fluid out of the wound.
• Examples: Yates, penrose
• Closed passive drains: Siphon effect of gravity and capillary action.
• Examples: Folley catheter, Robinson drain, NGT, ventriculoperitoneal shunt, chest tube (tube thoracostomy).
• Closed active drains: Generate active suction.
• Examples: Jackson-Pratt drain, “Redivac” drain, “Minivac” drain, Hemovac drain.
• T-Tube
• Rarely used. Post-open exploration of the bile duct after intraoperative cholangiogram.
• Surgical procedure superseded by Endoscopic retrograde
• cholangiopancreatography (ERCP). Decompresses the bile duct system and confirms patency of the biliary tree and absence of further stones.
• Percutaneous drain
• Draining 600 ml per day initially and slowly reducing.
• After around 10 days, the tube should have created a tract to the skin through a fibrotic reaction and it should then close.
• Before removing it, clamp it for 24 hours and look for signs of obstructive jaundice. A T tube cholangiogram is often performed prior to it to ensure patency of the biliary duct.

Nutrition In Surgical Patients

Key Points

• Timely nutrition reduces catabolic state and skeletal muscle wasting.
• Pre-existing malnutrition is common in surgical patients.
• Advanced malignancy, sepsis from appendicitis or diverticulitis, prolonged vomiting and bowel obstruction while the patient is NPO, could all lead to excessive catabolic states and require early nutritional support.
• Albumin and transferrin levels are poor indicators of nutritional state.
• Prealbumin has been shown to be a useful test of nutritional status and progress, although not routinely used in clinical practice.

Poor Nutrition Leads To the Following ERIC NOT AS HEADING?

• Impaired albumin production.
• Impaired wound healing and collagen deposition (e.g., wound dehiscence).
• Impaired organ healing in anastomosis (e.g., fistula after bowel resection and anastomosis).
• Skeletal muscle weakness (ICU myopathy).
• Reduced neutrophil and lymphocyte function leading to higher rates of infection.
• Prolonged hospitalization.

Body Mass Index (BMI)

• Most commonly used measure of nutrition. Weight in kg/height in meters2.
• Severely underweight - BMI less than 16.5kg/m2
• Underweight - BMI under 18.5 kg/m2
• Normal weight - BMI greater than or equal to 18.5 to 24.9 kg/m2
• Overweight – BMI greater than or equal to 25 to 29.9 kg/m2
• Obesity – BMI greater than or equal to 30 kg/m2
• Obesity class I – BMI 30 to 34.9 kg/m2
• Obesity class II – BMI 35 to 39.9 kg/m2
• Obesity class III – BMI greater than or equal to 40 kg/m2 (also referred to as severe, extreme, or massive obesity)
• Handgrip strength is a useful measure of skeletal muscle strength and correlates with clinical outcomes, including malnutrition.

Types of Nutritional Support

• Oral
• Always the preferred route, if available.
• Start oral feeding early, if possible, and avoid excessively long pre-operative fasting and post-operative fasting.
• Promotes normal GI flora and mucosal balance.
• Chewing gum has been found to stimulate and improve GI function.
• Nasogastric or nasojejunal
• Nasojejunal tubes used if NGT is not possible, e.g., severe vomiting, gastric resection, gastric outlet obstruction.
• Feeding gastrostomy or jejunostomy
• Gastrostomy: For patients with functioning GIT but cannot swallow/anorexia (PEG = percutaneous endoscopic gastrostomy). Figure 1.4
• Jejunostomy: To bypass stomach, e.g., ulcers, post-oesophagectomy.
• Total parenteral nutrition (TPN)
• May be given to patients in whom the oral and NG/NJ route is not possible or as a bridge until full enteric feeding is achieved (e.g., extensive bowel resection, severe catabolic state with fistula and bowel resection such as in Crohn’s disease, pancreatitis).
• Peripheral TPN must be given through a large diameter vein–most given via central vein (e.g., central lines or PICC lines).
• Hyperosmolar solution can lead to tissue damage if extravasation occurs.
• Important to monitor electrolytes for electrolyte imbalance.

Figure 1.5 Gastrostomy

• Central TPN
• Central line (central venous catheter): typically placed in the internal jugular vein, subclavian vein or femoral vein.
• Hickmann line: Dedicated tunnelled catheter.
• PICC line (peripherally inserted central venous catheter) - Figure 1.5
• Risks of central venous catheterisation include:
• Haematoma/haemorrhage.
• Line superinfection, infection to surrounding soft tissues.
• Line obstruction/kinking/malplacement.
• Damage to surrounding structures from malplacement
  • • • Pneumothorax
      • Air embolism
      • Cardiac dysrhythmias
      • Carotid artery dissection
• TPN-associated complications
• Hyperosmolarity
• Electrolyte imbalance.
• Lack of glycaemic control.
• Liver dysfunction, cholestasis and pancreatic atrophy.
• Nutrient deficiency
• Fluid overload
• Patients on TPN require monitoring of:
• Daily U&E and glucose until stabilised on TPN.
• LFTs twice weekly
• Magnesium, copper, manganese, zinc, phosphate weekly.

Figure 1.6 PICC line.

MEDICATIONS IN SURGERY

Medications In Surgery

Pre-Operative Medicines Management

• Most drugs should be continued up to and including the day of surgery because of the risk of compromising disease control if suddenly stopped. Table 1.3
• Calcium channel blockers and beta blockers must be continued.
• Patients on long-term steroids are at risk of adrenal atrophy and therefore unable to mount a physiological stress response to surgery. Severe hypotension can occur if steroids are discontinued.
• “Sick day rules”: Patient’s steroid dose is doubled to counter the increased steroid requirement when patient is ill. In surgery, at induction of anaesthesia, the patient should be given IV steroids.

Table 1.3 Pre-Operative General Guidelines for Medications Prior to Surgery. Please refer to local policies and procedures.

Patients On Warfarin

• Perioperative warfarin decision-making should consider the patient’s underlying thrombotic risk balanced against the bleeding risk associated with the surgery or procedure.
• Normal target INR is usually 2.5 (desirable range, 2.0-3.0).
• In patients with mechanical heart valves and some other conditions, the desirable range INR is usually higher, between 2.5-3.5.
• If warfarin needs to be stopped prior to a surgical procedure, please follow local hospital’s anticoagulation guidelines. In the absence of such arrangements, check INR 7 days prior to operation or procedure:
• If INR 1.5 – 1.9: discontinue 3 or 4 days prior to operation or procedure
• If INR 2.0 – 3.0 discontinue 5 days prior to operation or procedure
• If INR > 3.0 discontinue at least 5 days operation or procedure – discuss with haematologist.
• This should allow the INR to fall to 1.4 by day of operation or procedure.
• Check INR on admission to ensure safe to proceed with surgery or procedure.
• If bridging is required, this should either be started after 2 or 3 doses of warfarin being omitted or, if checking INR, when INR falls below 2.0. The last dose of therapeutic LMWH or UFH (unfractionated heparin if impaired renal function) should be at least 24 hours before surgery.
• Restart warfarin 12–24 hours post-procedure if the patient is tolerating oral intake, and there are no unexpected surgical issues that would increase the bleeding risk. Table 1.4
• 24 hours post-procedure (48 to 72 hours if major procedure), restart therapeutic dose of LMWH or UFH, continue until INR in desirable range. Prophylactic dose of LMWH or UFH might be started 2-4 hours postoperatively until therapeutic LMWH or UFH can be restarted.
• Stop LMWH or UFH once INR within desirable range.

Table 1.4 Guidelines for Warfarin Reversal

* IV vitamin K can be used for warfarin reversal within 4-6 hours. Oral vitamin K can be used for slow warfarin reversal within 24 hours. Rapid and complete warfarin reversal in major bleeding (see below), within 15 minutes, can be achieved by the administration of prothrombin complex concentrate associated with IV vitamin K.

Reversing Warfarin

• If there is risk of severe bleed (major bleeding), causing bleeding into a confined space (e.g., intracranial, intraocular, retroperitoneal, compartment syndrome), active bleeding with hypotension, or an invasive procedure is required to stop bleeding, warfarin should be stopped and IV vitamin K 5 mg should be administered slowly. Prothrombin complex concentrate should be also administered (50 units/kg) and fresh frozen plasma is an alternative (15ml/kg), however the later might not fully reverse the effect of warfarin.
• Conservative strategies such as interruption of warfarin use and oral vitamin K are suitable options for non-significant bleeding with alterations of INR.

Table 1.5 Common medications Used in Surgical Patients (please refer to current British National Formulary – BNF for detailed information on medications including dosing, side effects, contraindications and cautions).

Table 1.6 Laxatives Used in Surgical Patients

Fluids In Surgical Patients

Common Indications

• Daily maintenance (2.5 L):
• 25-30 ml/kg/day of water
• 1 mmol/kg/day of sodium, potassium, chloride
• 50-100g/day of glucose (glucose 5% contains 5g/100ml of glucose).
• Replace any fluid deficit:
• Hypovolaemia
• Shock, dehydration, low urinary output, excess fluid loss (e.g., vomiting), third space losses.
• Reduced fluid intake: NPO status pre-/post-operatively, reduced Glasgow Coma Scale (GCS).
• Sepsis
• Replace ongoing losses
• Stoma, fistula, drains, urinary catheter, NGT
• Burns
• Vomiting
• Diarrhoea
• Fever

Assessing Fluid Balance

• Hypovolemic Signs
• End of bed charts: Reduced urinary output, tachycardia, postural hypotension, low blood pressure (late).
• Patient’s peripheries: Reduced capillary refill time, cool peripheries, reduced skin turgor.
• Patient’s face: sunken eyes
• U&E: Higher urea and creatinine (AKI); higher Na+.
• Hypervolemic Signs
• Increased respiratory rate, tachycardia, hypertension, increased central arterial pressure and pulmonary artery pressure due to increased mean arterial pressure (MAP) and circulatory overload.
• Patient’s neck: Raised jugular venous pulse.
• Patient’s chest: Bibasal crepitations.
• FBC: Low haematocrit
• U&E: Lower urea and creatinine; lower Na+.
• CXR: Pulmonary oedema.

Fluid Requirements

• Normal daily fluid intake = 2.2 L (food/drink), 0.3L (metabolism)
• Normal daily losses = 2.5 L
• Urine = 1.5L
• Insensible = 0.9 L (e.g., from skin, lungs)
• Stool = 0.1L
• Electrolytes 1mmol/kg/day of Na, K and Cl.

Fluid Compartments

• H2O = 60% of body weight. 70kg male = 42L
• Rule of thirds (breakdown of fluid compartments):
• Extra-cellular fluid (ECF) = 1/3 = 14L
• Intravascular/plasma = 25% = 3.5L
• Interstitial = 75% = 10.5L
• Intra-cellular fluid (ICF) = 2/3 = 28L

Fluid Types

• Colloids
• Types:
• Natural: Blood, fresh frozen plasma (FFP), albumin.
• Synthetic: Gelofusine (gelatin-based), Voluven (starch-based).
• Mechanism of action:
• Higher osmotic pressure
• Initially remains in intravascular volume and intravascular expansion (larger molecules do not pass easily through vascular endothelium)
• Uses

Replacement fluids due to major haemorrhage/intravascular loss. Table 1.8

• Disadvantages
• NOT for usual hydration
• Expensive
• Risks: Anaphylaxis and coagulopathy (latter more associated with starch- based colloids)
• Crystalloids
• Mechanism of action:
• Equal distribution across all fluid compartments (smaller molecules dissolve easily and pass freely through vascular endothelium).
• Types:
• Hartmann’s or normal saline are usually used for fluid maintenance and majority of fluid resuscitation. Table 1.7
• Advantages:
• Cheaper
• Less risks

Table 1.7 Types of Crystalloid Fluids

Table 1.8 General Guidance on IV Fluid Prescription Rates and Indications

Fluid Challenge

• Indications: Shock, low urine output.
• Prescription: 500 ml of normal saline/ Hartmann’s over 30 min (250 ml if frail/overload risk).
• Result: If urine output improves, this suggests that hypovolaemia was the cause of low urine output.

Special Circumstances

• Children
• Dextrose/saline (calculate according to guidelines).
• GI loss
• Replace K+ if patient profusely vomiting or has diarrhoea or high output stoma.
• Heart failure
• Slow rate
• Renal failure
• Caution with electrolytes, especially K+
• Liver failure
• Predisposed to raised Na+ and low
• Albumin
• Consider albumin-based solution
• Avoid normal saline

Special Surgical Circumstances

• Acute blood loss
• Wide bore cannulae
• Prescribe colloid/normal saline/Hartmann’s until blood if available
• Consider O-negative blood until crossmatched blood is available.
• Low urine output:
• Aim for 0.5–1 ml/kg/hr (equivalent to 30 ml/hr).
• Ensure catheter is inserted correctly and not blocked
• Fluid challenge indicated
• Pancreatitis:
• Large third space fluid losses
• Fluid resuscitation indicated
• Post-operative
• Check operative notes for documentation of intra-operative losses–replace losses
• Replace losses from drains etc.
• Shock
• Replace with colloid or normal saline.
• Burns
• Parkland formula = 4 ml Hartmann’s solution × body weight (kg) × % TBSA (rule of 9’s) = volume of fluid to be administered in the first 24 hours.
• More information found in Chapter 13

Administration of Blood Products

• In the non-haemorrhaging patient, the rate of transfusion will depend on age, clinical scenario and cardiac status.
• From starting the infusion to completion, the total transfusion time should not exceed 4 hours for 1 unit of RBCs; average 2–3 hours.
• Except in the massive transfusion setting, transfusion rates for blood should not exceed 2-4 ml/kg/hour.
• Both plasma and platelets are transfused over 30–60 minutes.
• Monitor For Reactions
• Severe reactions are most likely to occur within the first 15 min/50 ml of each unit and patients should be closely monitored during this period.
• The most common problem associated with transfusion is a rise in temperature, which may be related to the transfusion process itself or to the underlying illness.
• In general, if the temperature rises >1.5°C, the transfusion should be stopped, and a transfusion reaction should be assessed/ruled out before continuing with the transfusion.
• Transfusion reactions can be associated with significant morbidity. They should be promptly recognised and managed accordingly. All suspected reactions should be reported immediately to the hospital transfusion laboratory.
• Elderly patients or those with compromised cardio-respiratory function will require closer monitoring.
• Consider transfusing in a slower rate (maximum of 4 hours) and the administration of furosemide (20 mg) with every unit of RBC transfused.
• Always individually assess clinically prior to the administration. If possible, restricting transfusion to one unit of RBC in each 12 hours period should reduce the risk of left ventricular failure.
• Assess post-transfusion haemoglobin levels
• In general, the rule is that 1 unit of RBC should increase the haemoglobin levels by 1g/dL (based on a 70 kg patient).
• However, haemoglobin increments can vary according to individual donor, component, and recipient characteristics.
• In the normovolaemic patient who is recovering from an acute bleeding episode, the haemoglobin levels can be checked 15 minutes after the transfusion has been completed.

Sepsis

Diagnosis of Sepsis

• Old method
• Two or more of systemic inflammatory response syndrome (SIRS) criteria:
• Respiratory rate > 20 breaths/minute or PaCO2 <32mmHg
• Heart rate > 90 beats/minute
• Temperature < 36°C, or > 38.3°C
• WCC < 4 × 10⁶/L, or > 12 × 10⁶/L.

AND a suspected or present source of infection

• Newer method:
• Sequential Organ Failure Assessment (SOFA) score: Assessment of respiration, coagulation, liver, cardiovascular, central nervous system and renal parameters (or quicker method qSOFA score).
• A SOFA score ≥2 (organ disfunction) in the presence of infection is required for the diagnosis of sepsis.
• Please refer to the table below for the qSOFA parameters. Patients with suspected infection have poor outcomes if they present at least two or more signs from the qSOFA score. Table 1.9.

Table 1.9 qSOFA Score for Sepsis

Adjunctive Investigations

• Look for cause
• Dipstick urine and urinalysis
• Culture of indicated sample–urine/stool/wound/skin/IV lines/CSF/aspirate (joint, pleural, ascitic, abscess)/bone
• CXR
• Do not forget to check glucose levels–diabetes predisposes infection and diabetic patients often have abnormal glucose levels during infection

Table 1.10 Diagnosis of Severe Sepsis. If presence of any organ disfunction, it is severe sepsis.

Severe Sepsis Management

• Any organ disfunction: this is severe sepsis.
• Seek immediate senior review (registrar/consultant)
• Reassess frequently in first hour
• Consider other investigations/management Consider critical care review

Septic Shock

• A subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.
• Septic shock is associated with hospital mortality rates greater than 40%.
• Look for signs of septic shock after fluid challenge.

Management of Septic Shock

• Consultant review
• Critical care consult
• Consider transfer to higher level of care